Treatment Of Unruptured Intracranial Aneurysms Research Articles

Toward Grading Subarachnoid Hemorrhage Risk Prediction: A Machine Learning-Based Aneurysm Rupture Score.

Existing approaches neither provide an accurate prediction of subarachnoid hemorrhage (SAH) nor offer a quantitative comparison among a group of its risk factors. To evaluate the population, hypertension, age, size, earlier subarachnoid hemorrhage, and location (PHASES) and unruptured intracranial aneurysm treatment score (UIATS) scores and develop an Artificial Intelligence-based 5-year and lifetime aneurysmal rupture criticality prediction (ARCP) score for a set of risk factors. We design various location-specific and ensemble learning models to develop lifetime rupture risk, employ the longitudinal data to develop a linear regression-based model to predict an aneurysm's growth score, and use the Apriori algorithm to identify risk factors strongly associated with SAH. We develop ARCP by integrating output of Apriori algorithm and ML models and compare with PHASES and UIATS scores along with the scores of a multidisciplinary team of neurosurgeons. The PHASES and UIATS scores show sensitivities of 22% and 35% and specificities of 76% and 79%, respectively. Location-specific models show precision and recall of 93% and 90% for the middle cerebral artery, 83% and 80% for the anterior communicating artery, and 80% and 80% for the supraclinoid internal carotid artery, respectively. The ensemble method shows both precision and recall of 80%. The validation of the models shows that ARCP performs better than our control group of neurosurgeons. Data-driven knowledge produces comparisons among 61 risk factor combinations, 11 ranked minor, 8 moderate, and 41 severe, and 1 of which is a critical factor. The PHASES and UIATS are weak predictors, and the ARCP score can identify, and grade, risk factors associated with SAH.

Safety and effect of pipeline flex embolization device for complex unruptured intracranial aneurysms

To investigate the safety and short-term effect of Pipeline Flex devices in the treatment of complex unruptured intracranial aneurysms, a retrospective study was performed for patients with complex unruptured intracranial aneurysms who were treated with the Pipeline Flex embolization device (PED Flex device) combined with or without coiling. The clinical, endovascular, and follow-up data were analyzed. One hundred and thirty-one patients with 159 complex unruptured cerebral aneurysms were treated with the PED Flex device, with 144 Flex devices deployed. Periprocedural complications occurred in four patients, resulting in the complication rate of 3.1%, including ischemic complications in three patients (2.3%) and hemorrhagic complication in one (0.8%). At discharge, the mRS was 0 in 101 (77.1%) patients, 1 in 25 (19.1%), 2 in four (3.1%), and 4 in one (0.8%), with the good prognosis rate (mRS 0–2) of 99.2%. Clinical follow-up was carried out in 87 (66.4%) patients 3–42 months after the procedure, with the mRS of 0 in 78 (89.7%), 1 in five (5.7%), 2 in three (3.4%), and 4 in one (1.1%). No significant (P = 0.16) difference existed in the mRS at discharge compared with that at clinical follow-up. Angiographic follow-up was performed in 61 (46.7%) patients with 80 (50.3%) aneurysms at 3–40 months, with the OKM grade of D in 57 (71.3%) aneurysms, C in eight (10%), and B in 15 (18.8%). Asymptomatic instent stenosis occurred in four patients (6.6%). In conclusion: The treatment of complex intracranial aneurysms with the Pipeline Flex embolization device may be safe and effective, with a high complete occlusion rate, a decreased complication rate, and a good prognosis rate at medium follow-up.

Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance

BackgroundThe literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time.MethodsA cross-sectional study...

Abstract Number ‐ 115: A Case of Post‐Pipeline Headache : New Post‐Flow Diversion Headaches for Intracranial Aneurysm

Introduction Flow diversion using devices such as the “pipeline” stent is now a common treatment for unruptured intracranial aneurysms. Though much is known about the efficacy of the device, less is reported regarding potential side effects. We aimed to describe a case of giant aneurysm with new onset and severe headache Post‐ Pipeline flow diversion stent application. Methods A 70‐year‐old female patient was admitted to the neurology outpatient clinic with complaints of diplopia and drooping of the left eyelid that started three months ago. Neurological examination revealed decreased visual acuity and total ophthalmoplegia in the left eye. In neuroimaging,semi‐thrombosed aneurysm, 20*25*20 mm in size, compressing the optic nerve and cavernous structures was observed in the left internal carotid artery cavernous segment. In digital subtraction angiography, a narrow neck, 20*25*22 mm giant aneurysm was observed in the left ICA C4 segment in three‐dimensional imaging. In premedication, were started seven days ago acetylsalicylic acid 100 mg 1*1 and 48 hours ago ticagrelol 2*90 mg and Pipeline 4.25*30 mm flow diverter was applied to cover the aneurysm neck under general anesthesia. One day after the procedure, the patient developed a new headache behind the left eye, throbbing, sensitive to sound and light, unresponsive to paracetamol and non‐steroidal anti‐inflammatory agents.In contrast‐enhanced cranial MRI, an aneurysm causing a central thrombosed hypointense mass effect was observed in the left cavernous structure neighbor with a peripheral enhanced, hyperintense T2 Flair sequence compatible with peripheral vasogenic edema. Pulse 1 gram/day steroid treatment was applied to the patient for three days.The patient’s headache completely regressed at the end of the third month, and perianeurysmal inflammation disappeared in the same contrast‐enhanced cranial MRI.In the 12th month post‐procedure imaging of the patient, it was observed that the aneurysm was completely occluded. Results In the case, we reporta patient with neurologic worsening after flow‐diverter treatment for unruptured cerebral aneurysms. We found MR imaging evidence of perianeurysmal brain inflammation after the therapeutic thrombosis of the sac to be the main cause explaining clinical aggravation. Consequently, we may consider a perianeurysmal brain inflammation when encountering the association of a postprocedure headache with an increase in previous compressive signs, possibly associated with MR imaging signs of inflammation1,2. We tried pulse steroid therapy, which is accepted as the first‐line treatment for postimplantation syndrome after endovascular repair of aortic aneurysms in the literature for a patient who did not respond dramatically to nonsteroidal anti‐inflammatory therapy3.We experienced a significant improvement in the patient’s clinical findings and contrast‐enhanced MRI findings after steroid treatment. Conclusions An inflammatory reaction may aggravate, transiently, clinical symptoms after aneurysm treatment with a flow‐diverter device. Further research is needed to better understand the underlying mechanisms as well as to achieve better prevention strategies.

Abstract Number ‐ 141: Microemboli Monitoring After Intrasaccular Flow Disruption: Single‐center Experience

Introduction The management of wide‐necked bifurcation aneurysms can be challenging due to multiple factors. Intrasaccular flow disruption with the Woven EndoBridge (WEB) has demonstrated a safe and effective profile. Current microemboli data after the WEB device placement is non‐existent. We evaluated the rate of embolic signals (MES) after WEB device implantation. Methods We performed a retrospective analysis of a prospectively maintained database including patients who underwent WEB device implantation for the treatment of unruptured intracranial aneurysms between 2021 and 2022. Variables studied included patient demographics, modified Rankin Scale (mRS) before and 3 months post‐treatment, comorbidities, aneurysm characteristics, platelet inhibition tests, and activated clotting time. All patients were on aspirin and a P2Y12 inhibitor and had therapeutic levels on platelet aggregation assays. Intraoperative heparin was given in all cases to keep a therapeutic ACT. P2Y12 drugs were stopped after the procedure. In all patients, MES monitoring was performed in the immediate postoperative period and >12 hours after the procedure. Results 34 patients with 34 aneurysms were analyzed. Mean age was 67.4 years and 85% were females. Mean aneurysm size was 13.1 ± 2.0 mm and mean neck size 4.4 ± 1.5 mm. Locations were middle cerebral artery bifurcation and M1‐M2 segment (n = 13), basilar artery tip (n = 10), anterior communicating artery (n = 8), internal carotid artery terminus (n = 2) and pericallosal artery (n = 1). A single WEB was implanted in 100% of the cases. MES were negative in all cases. 3‐month mRS remained stable or improved in all cases. No procedure‐related complications were seen. Conclusions Our findings reinforce the safety profile of intrasaccular flow disruption. These findings differ from a previous analysis of unruptured aneurysms in our institution where a 7.7% incidence of MES was reported after endovascular treatment of unruptured aneurysms with primary or assisted coiling.

Unruptured Intracranial Aneurysm:Indications and Outcomes

Since most unruptured intracranial aneurysms(UIA)are asymptomatic, it is important to determine treatment indications. The purpose of UIA treatment is to prevent rupture and relieve the patient's mental burden. Therefore, building a good relationship between doctors and patients is a major premise for one of the indications for surgical treatments. In addition, long-term follow-up of patients is necessary because endovascular treatment has the possibility of recurrence and retreatment. Since endovascular treatment is "possible" and "suitable" is different, it is necessary to determine the treatment policy from a radical point of view.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study

Background and PurposeIntracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen. Patients and MethodsAdult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented. Results and ConclusionsTwenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery.Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri‑operative protocol and an adequate therapeutic strategy are essential prerequisites.

Return to Work after Surgical Clipping versus Endovascular Treatment of Unruptured Intracranial Aneurysms: A Nationwide Registry–Based Study

PurposeTo assess return to work following the treatment of unruptured intracranial aneurysms (UIAs). Materials and MethodsThis retrospective, nationwide registry–based study included all adult patients of working age treated for a UIA in Norway between 2008 and 2018 who had a record of sickness leave on the day of treatment. Data from The Norwegian Patient Registry and The Norwegian Labour and Welfare Administration were linked on an individual level. Daily sickness and recipiency of disability benefits, as an indirect measure of working status, from 1 year before treatment to 1 year after treatment were analyzed. Return to work after endovascular treatment and surgical clipping was compared. ResultsIn total, 412 patients were included. Of patients who worked 1 year before treatment, 83% returned to work 1 year after treatment. The number of days from treatment to the first day back at work in a continuous 3-month working period was lower in patients who underwent endovascular treatment than in those treated with surgical clipping (median, 69 days; 95% confidence interval [CI], 51–87; vs 201 days, 95% CI, 163–239; P < .001). Return to work was more likely in patients who underwent endovascular treatment at 3 months after treatment (hazard ratio, 3.53; 95% CI, 2.54–4.93; P < .001). There was no difference in return to work at 6 and 12 months after treatment. ConclusionsThe treatment of UIAs affects patients’ postoperative working status. Patients treated endovascularly return to work earlier than those who undergo open surgery.

Is it time to rethink microsurgical training for the treatment of intracranial aneurysms in Australia?

BackgroundCase volume and complexity for microsurgical treatment of cerebral aneurysms have changed due to the growing use of endovascular therapy in clinical practice. The authors sought to quantify the clinical exposure of Australian neurosurgery trainees to cerebral aneurysm microsurgery. MethodsThis observational, retrospective cross-sectional study examined the Australian National Hospital Morbidity database for all admissions related to microsurgical and endovascular treatment of aneurysmal subarachnoid haemorrhage (aSAH) and unruptured intracranial aneurysms (UIAs) for the years 2008 to 2018. Procedural volumes were compared with neurosurgical trainee figures to investigate the rate of procedural exposure relative to the neurosurgical workforce. ResultsA total of 8,874 (41.6%) microsurgical procedures (3,662 for aSAH, 5,212 for UIAs), and 12,481 (58.4%) endovascular procedures (6,018 for aSAH, 6,463 for UIAs) were performed. Trainee exposure to microsurgery in aSAH declined from 9.1 to 7.3 cases per trainee per annum (mean 7.7), with case complexity confined mostly to simple anterior circulation aneurysms. There are significant state-by-state differences in the preferred treatment modality for aSAH. During the same study period, the number of microsurgical cases for UIAs increased (from 8.9 to 13.5 cases per trainee per annum, mean 11.0). Significantly more endovascular procedures are performed than microsurgery (10.7 to 17.0, mean 12.7 cases, for aSAH; 8.0 to 21.5, mean 13.7 cases, for UIAs). ConclusionsTrainee exposure to open aneurysm surgery for aSAH have significantly declined in both case volume and complexity. There is an overall increase in the number of surgeries for elective aneurysms, but this varies widely from state-to-state.

Ultra-short Echo-time MR Angiography Combined with a Subtraction Method to Assess Intracranial Aneurysms Treated with a Flow-diverter Device.

A flow-diverter (FD) device is a well-established tool for the treatment of unruptured intracranial aneurysms. Time-of-flight (TOF) MR angiography (MRA) is widely used for postoperative assessment after the treatment with FD; however, it cannot fully visualize intra-aneurysmal and intrastent flow signals due to the magnetic susceptibility from the FD. Recently, the utility of MRA with ultra-short TE (UTE) sequence and arterial spin labeling technique in assessing the therapeutic efficacy of intracranial aneurysms treated with metallic devices has been reported, but long image acquisition time is one of the drawbacks of this method. Herein, we introduce a novel UTE MRA using the subtraction method that enables the reduction in susceptibility artifacts with a short image acquisition time.

Predictive value of IOM in clipping of unruptured intracranial aneurysms – A prospective study from the surgeon's point of view

IntroductionIntraoperative neuromonitoring (IOM) of motor/somatosensory evoked potentials is a well-established approach for reducing ischemic complications after aneurysm clipping. Research questionTo determine the predictive validity of IOM for postoperative functional outcome and its perceived added value for intraoperative real-time feedback of functional impairment in the surgical treatment of unruptured intracranial aneurysms (UIAs). Material and methodsProspective study of patients scheduled for elective clipping of UIAs between 02/2019–02/2021. Transcranial motor evoked potentials (tcMEP) were used in all cases, a significant decline was defined as loss of ≥50% in amplitude or 50% latency increase. Clinical data were correlated to postoperative deficits. A surgeon's questionnaire was conceived. Results47 patients were included, median age 57 years (range 26–76). IOM was successful in all cases. In 87.2%, IOM was stable throughout surgery, although 1 patient (2.4%) demonstrated a permanent postoperative neurological deficit. All patients with an intraoperatively reversible tcMEP-decline (12.7%) showed no surgery-related deficit, regardless of the decline duration (range 0.5–40.0 ​min; mean: 13.8). Temporary clipping (TC) was performed in 12 cases (25.5%), with a decline in amplitude in 4 patients. After clip-removal, all amplitudes returned to baseline. IOM provided the surgeon with a higher sense of security in 63.8%. Discussion and conclusionIOM remains invaluable during elective microsurgical clipping, particularly during TC of MCA and AcomA-aneurysms. It alerts the surgeon of impending ischemic injury and offers a way of maximizing the time frame for TC. IOM has highly increased surgeons’ subjective feeling of security during the procedure.

Pathophysiological changes in cerebral energy metabolism after treatment of unruptured intracranial aneurysms: A prospective 31P-MR-spectroscopy study

Pathophysiological changes in cerebral energy metabolism after treatment of unruptured intracranial aneurysms: A prospective 31P-MR-spectroscopy study

Treatment Strategy of Unruptured Intracranial Aneurysms in Octogenarian Patients: A Single-Institution Experience.

To share our clinical insights into octogenarian patients with unruptured intracranial aneurysms (UIAs) and evaluate the treatment strategies for this demographic. A retrospective analysis was conducted on data from 134 patients with a follow-up exceeding 6 months, all enrolled in this study. We assessed the incidence rates (IRs) of aneurysm growth and rupture, along with potential predictors of aneurysm growth. Among the 134 patients, 99 (73.9%) underwent conservative management, 25 (18.7%) received coiling, and 10 (7.5%) underwent clipping. The mean age of the cohort was 81.8 years. The middle cerebral artery was the most common location for aneurysms. The mean aneurysm size was 4.9 mm, with sizes significantly larger in the treatment groups (coiling and clipping) compared to the observation group (4.4 mm in the observation group; 5.9 and 7.4 mm in the coiling and clipping groups, respectively). The proportion of aneurysms with a daughter sac was higher in the treatment groups compared to the observation group (6.1% vs. 44% [coiling] and 50% [clipping]). The IR of aneurysm growth was 5.9 per 100 person-years, and that of aneurysm rupture was 0.8 per 100 person-years. No factors were statistically significant for aneurysm growth. Age alone, especially in individuals over 80 years old, may not be a contraindication for UIA treatment. We recommend considering treatment in octogenarians with high-risk aneurysm features, such as a large aneurysm and the presence of a daughter sac, as the complication rates are low.

Candidate drugs for preventive treatment of unruptured intracranial aneurysms

Candidate drugs for preventive treatment of unruptured intracranial aneurysms

Therapeutic efficacy and complications of radial versus femoral access in endovascular treatment of unruptured intracranial aneurysms.

The transradial approach (TRA) in neuroendovascular treatment is known to have a lower risk of complications than the transfemoral approach (TFA). However, little research has focused on assessments of efficacy and risk of complications in the treatment of intracranial aneurysms. This study aimed to compare the efficacy and complications of TRA and TFA in coil embolization of unruptured intracranial aneurysms (UIAs) at our institution. Consecutive patients who underwent endovascular surgery via TRA or TFA at a single institution from 1 April 2019, to 28 February 2022, were retrospectively analyzed. Patients were classified into TRA and TFA groups and assessed using propensity-adjusted analysis for outcomes including fluoroscopy time, volume embolization ratio (VER), and complications. A total of 163 consecutive UIAs were treated with coil embolization during the 35-months study period. The incidence of minor access site complications (ASCs) was significantly higher with TFA (20%, 25/126) than with TRA (2.7%, 1/37; p = 0.01). Propensity-adjusted analysis (matched for age, sex, aneurysm volume, embolization technique, and sheath size) revealed that TRA was associated with a lower risk of minor ASCs (odds ratio, 0.085; 95% confidence interval 0.0094-0.78; p = 0.029). However, TRA did not differ significantly from TFA with respect to fluoroscopy time, VER, major ASCs, and non-ASCs. Coil embolization for UIAs via TRA can reduce risk of minor ASCs without increasing the risk of non-ASCs compared with conventional TFA, and can achieve comparable results in term of efficacy and fluoroscopy time.

Effect and safety of Tubridge flow diverter in the treatment of unruptured intracranial aneurysms

The effect and safety of the Tubridge flow diverting device are unknown in the treatment of intracranial aneurysms after optimization of the device, improvement in the deployment of the device, and accumulation of experience of using the device. This retrospective one-center study was performed to investigate the clinical effect and safety of the Tubridge flow diverting device in the treatment of unruptured intracranial aneurysms. Twenty-three patients with 33 unruptured intracranial aneurysms which were treated with the Tubridge device were retrospectively enrolled. The clinical data, endovascular procedure, complications, and follow-up were analyzed. Twenty-seven Tubridge devices were deployed to treat the 33 aneurysms, and the deployment was failed in 1 case, resulting in the success stenting rate of 96.3%. In 5 (15.2%) aneurysms, coils were loosely packed. Peri-procedural complications occurred in 2 patients (8.7%), including 1 procedure-related complication in which the distal end of a Tubridge device herniated into the aneurysm cavity. In another case, weakness of left upper limb occurred on the second day post procedure, with instent thrombosis being suspected, which was recovered after medication. No other complications occurred. Twenty-three (100%) patients had clinical follow-up 6 months later, with the mRS of 0 in 21 patients, 1 in 1, and 2 in 1. Five (21.7%) patients with 11 aneurysms underwent digital subtraction angiography at 6-month follow-up, with 8 aneurysms being completely occluded (Raymond grade I) and 3 aneurysms still visible (Raymond grade III). The Tubridge flow diverter may be safe and effective in the treatment of unruptured intracranial aneurysms with low perioperative complications and good follow-up outcomes even though multi-center and prospective clinical studies with a large size sample are still needed to validate these results.

Race as a factor in adverse outcomes following unruptured aneurysm surgery

IntroductionStrong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. MethodsData from the 2012–2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. Results7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07–1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. ConclusionOur nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

Incidence and Outcome of Peri-interventional Vasospasm During Endovascular or Microsurgical Treatment of Unruptured Intracranial Aneurysms.

Peri-interventional vasospasm (PIVS) is associated with high risk of delayed cerebral vasospasm (DCVS), delayed cerebral ischemia, and poor outcome after aneurysmal subarachnoid hemorrhage. However, the incidence rate associated with treatment of unruptured intracranial aneurysm (UIA) remains unclear. To define the incidence and clinical significance of PIVS in UIA repair based on intraoperative/peri-interventional digital subtraction angiography. A consecutive series of 205 patients who underwent UIA treatment by means of microsurgical clipping (n = 109) or endovascular coil embolization (n = 96) was assessed for the occurrence of PIVS. In all cases, PIVS was detected, measured, and classified using intraoperative/peri-interventional digital subtraction angiography. Severity of PIVS, association of PIVS with the development of DCVS, and neurological outcome were analyzed. Intraoperative PIVS was present in n = 14/109 (13%) patients with microsurgical clipping. Of these, caliber irregularities were mild (n = 10), moderate (n = 3), and severe (n = 1). In endovascularly treated patients, 6/96 (6%) developed PIVS, which were either mild (n = 3) or moderate (n = 3). Management in all cases included immediate intensive blood pressure management and application of topical papaverine or intra-arterial nimodipine immediately on detection of PIVS. No patient developed DCVS or lasting neurological deficits attributable to PIVS. This series revealed a relatively high overall incidence of PIVS (10%). However, no association of PIVS with the development of DCVS or poor outcome was found. In contrast to ruptured intracranial aneurysms, PIVS in unruptured intracranial aneurysms-if immediately and adequately addressed-seems to be benign and without sequelae for patient's functional outcome.

Radiation dose and fluoroscopy time of aneurysm coiling in patients with unruptured and ruptured intracranial aneurysms as a function of aneurysm size, location, and patient age

PurposeEndovascular treatment of unruptured intracranial aneurysms (UIAs) requires a risk–benefit analysis and adherence to diagnostic reference levels (DRLs). The national DRL (250 Gy·cm2) is only determined for intracranial aneurysm coiling in general, including ruptured intracranial aneurysms (RIAs). This study aims to investigate the dose in the treatment of UIAs and RIAs separately.MethodsIn a retrospective study design, dose area product (DAP) and fluoroscopy time (FT) were assessed for all patients undergoing intracranial aneurysm coiling between 2010 and 2021. DRL was set as the 75th percentile of the dose distribution. A multivariable linear regression analysis was performed to investigate DAP and FT for the two groups, UIA and RIA adjusted for patient age, aneurysm size, and location.Results583 (414 females, mean age 56.5 years, 311 UIAs) are included. In the overall population, DAP (median (IQR)) is 157 Gy·cm2 (108–217) with a median FT of 32.7 min (IQR 24.0–47.0). Local DRL is 183 Gy·cm2 for UIAs and 246 Gy·cm2 for RIAs. After adjustment for the other variables, the UIA and RIA groups have a significant effect on both DAP (p < 0.001; 95% CI − 68.432 – − 38.040) and FT (p < 0.001; 95% CI − 628.279 – − 291.254). In general, both DAP and FT increase significantly with patient age and aneurysm size, whereas the location of the aneurysm did not significantly change neither DAP (p = 0.171; 95% CI − 5.537–31.065) nor FT (p = 0.136; 95% CI − 357.391–48.508).ConclusionBoth aneurysm size and patient age were associated with increased DAP, whereas aneurysm location did not significantly change DAP or FT. The increased dose in patients with RIAs is likely equivalent to additional diagnostic cerebral four-vessel angiography performed in this group.